M. Perry

Diagnosis of frailty after a Comprehensive Geriatric Assessment: differences between family physicians and geriatricians

Background: To compare the outcomes of Comprehensive Geriatric Assessments by family physicians and geriatricians. Methods: An explorative observational study was conducted in six family practices (12 ambulatory family practitioners) and 1 geriatric department (4 hospital-based geriatricians) from a university medical center in Nijmegen (the Netherlands). As participants, we included 587 patients aged 70 years and older and registered in the six family practices. The main outcome measures were the judgment on the following: 1) absence or presence of frailty and 2) the state (good-fair-poor) on 8 underlying domains (physical, medication, cognition, sensory, instrumental activities of daily living scale, mobility, mental, and social) according to family Physicians and geriatricians based on a Comprehensive Geriatric Assessment. Results: Family physicians and geriatricians agreed on frailty absence/presence in 76% of cases. Geriatricians considered elderly more often frail than family physicians did (n = 294, 50% vs n = 213, 36%). Disagreement on frailty status was notably found in the patients who had less distinct, either poor or good, health states. Discordant frailty judgments, in which the geriatrician rated a person as frail and the family physicians did not, were related to geriatricians more often rating physical health as impaired. Further, geriatricians judgments of frailty were more strongly related to impaired scores on the domains cognition, sensory, mobility, and mental compared with family physicians judgments: odds ratios 79.3 versus 9.3, 7.6 versus 2.0, 25.0 versus 3.0, and 18.0 versus 2.2, respectively. Impaired physical health and problematic medication use had equally strong associations with frailty in geriatricians and family physicians: odds ratios of 11.5 versus 10.4 and 2.4 versus 2.5, respectively. Conclusions: Geriatricians more often judge patients as frail compared with family physicians and seem to evaluate the available information differently. With increasing collaboration between primary and secondary care, understanding these differences becomes increasingly relevant.

[Reducing fragmentation in the care of frail older people: the successful development and implementation of the Health and Welfare Information Portal].

Our fragmented health care systems are insufficiently equipped to provide frail older people with high quality of care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), an e-health intervention which aims (1) to facilitate self-management by frail older people and informal caregivers and (2) to improve collaboration among professionals. The ZWIP is a personal conference table, accessible through a secure internet connection, for multidisciplinary communication and information exchange for frail older people, their informal caregivers and professionals. After development, the ZWIP was implemented in seven general practices, and this process was evaluated by means of a mixed-methods study. Eventually, 290 frail older people and 169 professionals participated in the ZWIP. Most professionals were positive about its implementation. Facilitators for the implementation were the experienced need for improvement of interprofessional collaboration and the user-friendliness of the ZWIP. Barriers were the low computer-literacy of frail older people, start-up problems, preferring personal contact, and limited use of the ZWIP by other professionals. In sum, this article describes the successful development and implementation of the ZWIP, an e-health intervention which can reduce fragmentation in the care of frail older people.Reducing fragmentation in the care of frail older people: the successful development and implementation of the Health and Welfare Information PortalOur fragmented health care systems are insufficiently equipped to provide frail older people with high quality of care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), an e-health intervention which aims (1) to facilitate self-management by frail older people and informal caregivers and (2) to improve collaboration among professionals. The ZWIP is a personal conference table, accessible through a secure internet connection, for multidisciplinary communication and information exchange for frail older people, their informal caregivers and professionals. After development, the ZWIP was implemented in seven general practices, and this process was evaluated by means of a mixed-methods study. Eventually, 290 frail older people and 169 professionals participated in the ZWIP. Most professionals were positive about its implementation. Facilitators for the implementation were the experienced need for improvement of interprofessional collaboration and the user-friendliness of the ZWIP. Barriers were the low computer-literacy of frail older people, start-up problems, preferring personal contact, and limited use of the ZWIP by other professionals. In sum, this article describes the successful development and implementation of the ZWIP, an e-health intervention which can reduce fragmentation in the care of frail older people.SamenvattingOns gefragmenteerde zorgstelsel is onvoldoende in staat om goede zorg te bieden aan kwetsbare ouderen. Daarom ontwikkelden we het Zorg en WelzijnsInfoPortaal (ZWIP), een e-health interventie die beoogt om (1) zelfmanagement door kwetsbare ouderen en mantelzorgers te ondersteunen en (2) de samenwerking tussen hulpverleners te verbeteren. Dit ZWIP kan gezien worden als een persoonlijke, via internet toegankelijke overlegtafel voor multidisciplinaire communicatie en informatie-uitwisseling voor kwetsbare ouderen, hun mantelzorgers en hulpverleners. Het ZWIP werd geïmplementeerd in zeven verschillende huisartsenpraktijken en dit proces werd geëvalueerd met een mixed-methods onderzoek. In totaal namen 290 kwetsbare ouderen en 169 hulpverleners deel aan het ZWIP. De meeste hulpverleners waren positief over de implementatie. Bevorderende factoren voor de implementatie waren de ervaren noodzaak tot verbetering van de samenwerking tussen hulpverleners en het gebruiksgemak van het ZWIP. Belemmerende factoren waren beperkte computervaardigheden van kwetsbare ouderen, opstartproblemen, een voorkeur voor persoonlijk contact, en beperkt gebruik van het ZWIP door andere hulpverleners. Concluderend beschrijft dit artikel de succesvolle ontwikkeling en implementatie van het ZWIP, een interventie die de fragmentatie in de zorg kan verminderen. Dit wordt nog eens ondersteund door het feit dat een zorgverzekeraar het ZWIP als een declareerbare inspanning heeft erkend.

Identification of influencing factors and strategies to improve communication between general practitioners and community nurses: a qualitative focus group study

BackgroundnAs the number of patients with complex healthcare needs grows, inter-professional collaboration between primary care professionals must be constantly optimized. General practitioners (GPs) and community nurses (CNs) are key professions in primary care; however, poor GP-CN communication is common, and research into the factors influencing its quality is limited.nnnObjectivenTo explore patient-related GP-CN communication and facilitating and hindering factors, and to identify strategies to enhance this communication.nnnMethodnA qualitative focus group design was used to identify the facilitating and hindering factors and strategies for improvement. In a Dutch primary care setting, 6 mono-professional focus group interviews (3 meetings of 13 GPs; 3 meetings of 18 CNs) were organized between June 2015 and April 2016, recorded and transcribed verbatim. Two independent researchers performed the coding of these interviews, identifying their categories and themes.nnnResultsnResults show that, despite the regular contact between GPs and CNs, communication was generally perceived as poor in effectiveness and efficiency by both professions. Mutual trust was considered the most important facilitating factor for effective communication. Profession-specific factors (e.g. differences in responsibility and profession-specific language) and organizational factors (e.g. lack of shared care plans, no in-person communication, lack of time) may be of influence on communication. Participants suggestions for improvement included organizing well-structured and reimbursed team meetings and facilitating face-to-face contact.nnnConclusionnGP-CN patient-related communication benefits most from trusting inter-personal relationships. Inter-professional training programmes should address both professional and organizational factors and should be evaluated for their effect on quality of care.

Evaluation of DementiaNet, a network-based primary care innovation for community-dwelling patients with dementia: protocol for a longitudinal mixed methods multiple case study

Introduction Primary healthcare professionals will increasingly be required to manage and optimise their treatment for patients with dementia. With DementiaNet, we aim to reduce the burden of dementia on healthcare services and society through implementation and facilitation of integrated network-based care with increased dementia expertise. DementiaNet is designed as a stepwise approach including clinical leadership, quality improvement cycles and interprofessional training, which are tailor-made to the local context. For example, the composition of the network and improvement goals are tailored to the local context and availability. Here, we describe the linked evaluation study which aims to provide insight in effectiveness, process and mechanism of the DementiaNet approach through an innovative evaluation design. Methods and analysis We designed a longitudinal, mixed methods, multiple case study. Study population consists of two levels: (i) local DementiaNet networks of primary care professionals and (ii) patients and informal caregivers who receive care from these networks. At the start and after 12 and 24 months, quantitative data are collected for each network on: level of network maturity, quality of care indicators and outcomes reported by informal caregivers of dementia patients. We assess changes in networks over time and the association with quality of care and informal caregiver-reported outcomes. Throughout the study, logs about each network are registered. Additionally, semi-structured interviews with network members and informal caregivers will provide insight in experiences and opinions regarding effects and mechanisms through which changes in quantitative outcomes are effectuated. Rich narratives will be constructed about the development of the local networks using collected data. Ethics and dissemination The study protocol was reviewed by the local medical ethics committee; formal judgement was not required (protocol number: 2015–2053). The findings of this study will be disseminated through peer-reviewed publications, conference presentations and presentations for healthcare professionals where appropriate.

Actual involvement vs preference for involvement as an indicator of shared decision making

that are not evident in billing claims data. The entire clinical picture at presentation, past and present, will influence therapeutic decisions as well as eventual patient outcomes. We suggest selection bias is the unmeasured factor allowing 2 “theoretically” equivalent groups to have such different outcomes. We did consider the possibility that clinicians may preferentially perform spinal augmentation on the sickest patients so as to maximize their chances of survival—emergent spinal augmentation, if you will. Complications should then be highest immediately before the procedure, as patients clinically declare their need for more aggressive care. As Figure 2B in our article illustrates, however, preprocedure complications were less than postprocedure complications.1 In fact, there was a nadir in complications immediately before the procedure and a spike immediately after the procedure. We interpret these results to indicate that the majority of patients are not undergoing augmentation because of dire clinical need. Several methodological clarifications may be helpful. First, we did not stratify by treatment type (vertebroplasty vs kyphoplasty) in our analysis. However, we have compared these 2 treatments using these data and found no benefit of kyphoplasty over vertebroplasty. A recent randomized clinical trial comparing vertebroplasty with kyphoplasty also did not find benefit of one over the other.3 Second, we collected “baseline” comorbid conditions over the entire year prior to fracture. We included osteoporosis in that list, presumably the cause of the fracture. Unlike Edidin et al,2 we excluded all patients with diagnoses of cancer so as not to mix fractures due to metastases with those due to osteoporosis. Third, we used the date of fracture as baseline so that both groups would be compared relative to the same exposure (fracture) rather than starting the comparison when the augmented group had their procedure, which could be as late as 6 months later. Finally, Edidin et al failed to note in their letter that at the time of their article demonstrating the mortality benefits of spinal augmentation and, in particular, kyphoplasty, over conservative therapy, Dr Edidin was an employee and stockowner of Medtronic Inc, a manufacturer of kyphoplasty supplies.

Kwetsbaarheid als nieuw kompas bij diagnostiek, behandeling en monitoring van de oudere met bloedarmoede in de huisartsenpraktijk

SamenvattingBloedarmoede is een goed voorbeeld van een van de vaak voorkomende en meestal complexe gezondheidsproblemen bij ouderen. In deze klinische les maken wij duidelijk dat de diagnostiek en behandeling van een oudere met bloedarmoede aanzienlijk kunnen verbeteren door gestructureerd de mate van kwetsbaarheid in te schatten, bijvoorbeeld volgens de methodiek ontwikkeld in de Nijmeegse transitieprojecten van het Nationaal Programma Ouderenzorg (NPO).De diagnose ‘bloedarmoede’ dient daarbij niet bij andere grenswaarden gesteld te worden, maar verder technisch hulponderzoek moet afhankelijk worden gemaakt van de kwetsbaarheid zoals die kan worden vastgesteld door de huisarts. De individuele prognose die dit oplevert en de voorkeuren van de oudere zouden in de eerste lijn sturend moeten zijn in de mogelijkheden voor verder onderzoek en behandeling.De landelijke richtlijn Bloedtransfusie is in grote lijnen ook toepasbaar op ouderen, zij het dat aanpassingen op hun plaats zijn voor de meest kwetsbare groep. Dit geldt zowel voor de indicatiestelling als de begeleidende maatregelen en monitoring van de behandeling, die vooral op het welzijn van de oudere dienen te worden gericht. Navigatie van de oudere door deze richtlijn kan het beste plaatsvinden door goed naar het dagelijks functioneren van de kwetsbare oudere te kijken.De meerwaarde van het vaststellen van kwetsbaarheid in de eerste lijn wordt concreet gemaakt door de beschrijving van mw. Jansen, een 90-jarige thuiswonende dame met ernstige bloedarmoede.

De differentiële diagnose delier, dementie of depressie

SamenvattingPatiënten en hun familie wijten cognitieve achteruitgang vaak aan het ouder worden. De huisarts kan meestal een diagnose stellen. Door het niet stellen en bespreken van de diagnose krijgen patiënten en familie niet de meest passende behandeling en uitleg over het ziektebeeld. Ook is de zorg onvoldoende aangepast en anticiperend. Vanwege de verwevenheid van de klachten ‘geen fut of zin meer’, met de differentiële diagnose delier/dementie/depressie, kan het antwoord nooit direct een simpelweg ‘ja dat mag’ zijn. Dit artikel geeft een handreiking voor de probleemverheldering bij cognitieve stoornissen en de diagnostiek en het beleid bij verdenking op delier, depressie en dementie.